The Power of Professional Clinical Ethicists in Low- and Middle-Income Countries: An Ethiopian Perspective

Low and Middle-Income Countries (LMICs), such as Ethiopia, carry the greatest burden of morbidity and mortality and, correspondingly, face a plethora of ethically complex scenarios that are exacerbated by resource limitations, inequitable access to care, and cultural and language diversity. In their article “Reimagining Thriving Ethics Programs without Ethics Committees”, Mabel and colleagues detail how individuals with advanced training in clinical ethics – termed Professional Clinical Ethicists (PCEs) – can address the ethical needs of hospitals traditionally managed by hospital ethics committees (HECs). We agree with their primary proposition while noting that their arguments focus on high-income countries (HICs). We contend that special emphasis on developing a LMIC-PCE model is imperative when considering nuances related to clinical care in LMICs. A LMIC-PCE model would consider (in)equitable human and physical resource availability, complex social structures, and limited access to trained bioethicist-clinicians. We use our collective experiences in Ethiopia as a case example to highlight the need for a LMIC-PCE model. We detail nuances related to clinical practice and ethical dilemmas in Ethiopia and other LMIC contexts and suggest how a LMIC-PCE model can be used to further build ethical programs and capacity globally.

Health Disparities and Ethical Considerations in Ethiopia

LMICs face significant health disparities that span across generations. For example, the neonatal mortality rate in Ethiopia is 27.1 per 1000 live births compared to 3.2 in the United States and the general population’s life expectancy in Ethiopia is just 67.8 years.(Organization 2024) As Ethiopia’s average population ages, more resource intense conditions such as cardiovascular disease, stroke, and cancer now contribute significantly to patient care needs and early mortality.(Misganaw et al. 2017) Unfortunately, interventions for such non-communicable diseases are less cost-effective, generating ethical challenges related to fair access across and within hospitals. In Ethiopia, as with the rest of the world, moral dilemmas have become more complex as life-sustaining technologies have continued to develop alongside often increasing costs of such interventions. Ethiopian clinicians are proactively considering what role a trained ethicist can or should have in these decisions; while there are emerging frameworks in Ethiopia focused on research ethics, at present, structured mechanisms for clinical ethics support remain limited.

Even amidst common anecdotal evidence of ethical dilemmas, literature describing the Ethiopian clinical-ethical context is scarce. A 2015 study, focused on Ethiopian physician experiences in bedside rationing, found that doctors encounter numerous dilemmas due to resource scarcity especially in relation to surgical access, intensive care unit services, and drug prescriptions.(Defaye et al. 2015) Just as concerning, physicians in this study reported having inadequate guidance on how to handle these ethically-wrought situations.(Defaye et al. 2015) A need for clinical ethics reform and structured guidance for decision making has also been raised in regards to neonatal resuscitation (Rent et al. 2022) and removing life-sustaining treatment in pediatric patients(Tekleab and Lantos 2022). These experiences are not unique to Ethiopia; similar moral dilemmas amidst a lack of training and guidance have been published from numerous resource-limited contexts and LMICs worldwide.(Uddin et al. 2022; Khirikoekkong et al. 2023; Molyneux et al. 2021)

Ethics Education in Ethiopia

There is wide consensus that bioethics training must be strengthened in LMICs, yet there is limited existing capacity in this arena.(Bhutta 2002) In Ethiopia, options for advanced ethics training exist almost exclusively via partnership with HICs. For example, the Addis Center of Ethics and Priority Setting was established in 2017 through a collaboration between Addis Ababa University (AAU) and the University of Bergen.(Bergen 2023) Similarly, in 2023, AAU’s Master of Public Health program launched a Research Ethics Training Program in partnership with Johns Hopkins University.(Bioethics 2023) Alternatively, Ethiopians can enroll in certificate programs based in HICs. For example, the bioethics certificate program at The Children’s Mercy Center for Bioethics was created in 2012 and has had students from five African nations complete the program, including 6 from Ethiopia.(City 2024) Importantly, while these international and/or HIC programs provide valuable insights and training opportunities, their teachings may not fully align with local cultural and social structures.

A 2022 study of pediatricians in Ethiopia highlighted the need for local ethics training, reporting overall poor knowledge on core ethical principles and concluding that a HEC “capable of providing consultation, education, and case discussions could help doctors understand the principles that have evolved to guide decisions in ethically complex situations.”(Tekleab and Lantos 2022) Similar work, focused on ethics review within Institutional Review Boards (IRBs) of health science institutions in Addis Ababa, found that while most IRB members had attended trainings on the “fundamentals of research ethics”, few had training on consent, data safety and monitoring, or biomedical ethics.(Seralegne et al. 2023) Furthermore, most were public health professionals with scant patient-care experience and little direct exposure to navigating clinical ethical dilemmas. IRB members described their ethics training as “basic” and expressed a desire for more advanced training on issues such as consent, research ethics, and ethical challenges with traditional medicines.(Seralegne et al. 2023) Research/IRB and clinical ethics in Ethiopia could both be strengthened with enhanced support for initial provider/member training coupled with refresher trainings in clinical ethics.(Feleke et al. 2015)

The Ethics Committee and PCE Model in the Ethiopian Context

Mabel and colleagues note that HECs 1) provide ethics consultation to address patient-specific issues, 2) provide ethics education to healthcare providers, and 3) implement policies to support ethical practices, and are often constructed of volunteer-members. Such a committee would require several individuals with some experience in clinical ethics and, ideally, a few individuals with advanced training, all of whom had “spare time” to dedicate to the HEC. Unfortunately, there are numerous obstacles to generate an effective, sustainable, and productive HEC in Ethiopia. These include the rarity of provider-level ethics training, high patient-to-provider ratios, limited undedicated/available clinician time, and an already taxed healthcare system, amongst other factors. Similarly, Mabel’s definition of a PCE requires someone “whose full-time equivalent (FTE) is entirely dedicated to clinical ethics work.” While theoretically possible in HICs, in LMICs finding clinicians with adequate clinical ethics training and whose full FTE can be devoted to ethics, rather than patient care or other leadership roles, is currently a significant challenge.

Despite a growing recognition for the importance of ethics training for clinicians and researchers, there is significant work to be done before ethics education, professional development for physicians focused on ethics, and robust ethical support systems like HECs or PCEs are in place broadly across Ethiopia. In the meantime, an individual within a clinical department with some ethics training and clinical expertise will play the role of ethics consultant. This role is untitled, unpaid, yet essential. These de facto “clinician-ethicists” ideally have long-standing knowledge of the health system, institutional resources, and community-cultural contexts that impact patient care.

While falling short of the PCE definition proposed by Mabel et al, these population-specific “clinician-ethicists” offer some advantages to the PCE model. They are known and respected members of their departments, have often held leadership roles in the hospital, and remain closely linked to their patient population by providing direct clinical care even while serving in ancillary roles within the health system. As more “clinician-ethicists” are trained, promoting collaborative education among colleagues and creating opportunities to discuss ethical issues beyond specific patient populations, the capacity for comprehensive ethical support in Ethiopia will be greatly enhanced.

Global Ethics and Caution Against Moral Imperialism

With the paucity of existing ethical infrastructure in Ethiopia and other LMICs, it is important to develop this capacity without exhibiting “moral imperialism”.(Widdows 2007) Western bioethics is predominantly individualistic and principlist, while non-western ethics considers the individual more strongly within the community.(Widdows 2007) These approaches are not mutually exclusive. For example, in LMICs, the notion of “autonomy” may need to be revisited in the context of traditional family and community structure while still honoring the right of an individual to make decisions and consent to medical care. Furthermore, we must remember that ethical competence is a skill, not a core set of rules, that must be deftly applied in various contexts and “home” settings. Indeed, ethics knowledge scores amongst Ethiopian clinicians parallel years of experience, suggesting that while modern (i.e. Western) bioethical principles may conflict with traditional practices in Ethiopia, education is likely effective in modifying one’s approach to ethically complex situations.(Tekleab and Lantos 2022) To develop locally grounded ethical practices, provider-level clinical ethics training in Ethiopia should pair standardized clinical training with contextually relevant dilemmas as case examples to solidify educational points in ethics training.

Conclusion

The future of clinical ethics in Ethiopia will rely on building upon the existing work of clinician-ethicists, expanding ethics education, and establishing formal structures that support ethical decision-making across all healthcare sectors. By integrating culturally relevant ethical frameworks and enhancing clinician training, Ethiopia can create a sustainable and contextually appropriate ethics infrastructure that addresses the unique challenges of healthcare in resource-limited settings. In the meantime, health systems in Ethiopia must support the clinician-ethicists, as the current standard of care, so that they can continue to provide tailored ethical consults, within their areas of clinical expertise, and directly serve their patients at bedside.